Behavioral Health Fund

Consent to Release Information: Behavioral Health Fund

Please look over this document to make sure you are OK with YourPath sharing your information with other people or organizations. There are different reasons we share this information. Please ask if you want help understanding what we share and why.
Your Name*

First NameLast Name
Phone Number*
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Information to be disclosed: I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV),mental health and substance use. I authorize the release or disclosure of the substance use disorder records below:*

All my substance use disorder recordsFull comprehensive assessmentDiagnostic InformationDemographic informationOther
I consent to the release of information between YourPath and the following Behavioral Health Fund administered by the county below:*
Please select the county you currently live in
Administrator Phone Number

Area CodePhone Number
Administrator Fax Number

Area CodePhone Number
Administrator Email:
Administrator Address (if known)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What purpose are you authorizing the release of your information for?*

Care, Treatment, and Services fundingReferralsLegal/Court Ordered ServicesOther
By signing this form,

I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically within one year.

I understand that I may be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or healthcare operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I am aware I can be provided a copy of this form upon request.
Date of Client Signing*

MonthDayYear
Client Signature*

Clear
Is the client unable to sign for themselves and has a legal representative?

YesNo/NA
If the client is unable to sign due to legal incapacity, the signature of the client's personal representative is required. Documentation of the personal representative’s legal authority will be requested and uploaded into client's electronic medical record.
Representatives Name
Date of Representative's Signature, if client is unable to sign

MonthDayYear
Date
Legal Authority:
Legal Authority's Phone Number

Area CodePhone Number
Legal Authority's Email
example@example.com
Representative's Signature

Clear
Should be Empty: